The term ascites refers to a collection of fluid that accumulates in the abdomen and more precisely in the peritoneal cavity.
It is an easily diagnosed clinical condition because its manifestation is clearly visible with a typical swelling of the abdomen that takes on the appearance of the “toad” body (defined as Batracian abdomen) and on its surface, given the stretching tension of the skin , the more superficial venous networks are clearly evident in their course. Furthermore, the collection of fluid leads to an extension of the navel and in some cases to the formation of umbilical or inguinal hernias which are frequent features in abdominal ascites .
In order to define the condition of abdominal swelling as actual ascites , the accumulated fluid must be greater than half a liter, but sometimes this volume can reach up to 5 liters, in some cases leading the subject to respiratory complications.
What are the causes of ascites
why this condition can occur
What are the causes of ascites
It is good to clarify, from now on, that ascites in itself is not a disease but is simply a clinical sign of a triggering pathology. The causes can be of a cardiovascular, renal, hepatic , pancreatic, inflammatory and neoplastic nature(some neoplasms increase the amount of fluid in the abdominal area, especially in the case of tumor pathologies affecting the peritoneum).
Let’s go to see in more detail the most common pathologies connected to ascites for each type.
Cardiovascular causes
The main cardiovascular cause of ascites is attributable to portal hypertension , a condition that occurs when the portal vein is subject to an increase in blood pressure.
The portal veinit has the task of collecting blood from the so-called splanchnic organs (stomach, spleen, pancreas, small intestine) and in normal conditions it has a pressure of 5-10 mmHg, but as a result of pathological processes this pressure can triple and even quadruple. What mechanisms lead to this pressure increase
In general, the pressure increase is linked to phenomena of venous thrombosis or obstruction, as in the case of liver cirrhosis .
Another common cardiovascular cause of ascites is heart failure. In this case there is a condition of heart failure with consequent hypertension of the right heart which in turn affects the pressure of the portal vein, in a process similar to that of portal hypertension.
Finally, there is also constrictive pericarditis , a phenomenon whereby a thickening of fibers in the heart is formed which leads to an increase in pressure.
Hepatic causes Hepatic
diseases are those most involved in the onset of ascites , for a percentage that is close to 80% of cases.
The main and most important cause of ascites is attributable to pathologies affecting the liver and liver cirrhosis .Cirrhosis leads to an imbalance of liquids, due both to a protein deficit (a situation of hypoalbuminemia, low albumin is created ) and to an increase in renal sodium retention and therefore water for compensation.
Cirrhosis also gives rise to a problem in the circulation of the lymph inside the liver, with a consequent increase in pressure and an increase in fluids that are no longer properly reabsorbed.
Further complications cannot be excluded, in fact, in about 30% of cases of liver cirrhosis, ascites becomes infected due to the passage of bacteria from the intestine to the peritoneal cavity. In these cases we speak of bacterial peritonitis .
There is also a rather serious clinical condition of cirrhosis, which is accompanied by renal insufficiency, which takes the name of hepato-renal syndrome, and which can lead to death if not promptly intervened.
Renal causes
The most common form of renal pathology leading to ascites is nephrotic syndrome , in which, similarly to what happens for cirrhosis, there is a decrease in proteins (in particular albumin in a condition that takes the name of hypoalbuminemia) and to an increase in fluid retention.
Neoplastic causes
In these cases, ascitesit develops following tumor processes that originate in the stomach, liver, ovary and breast, which metastasize in the abdominal cavity, localizing in the peritoneum. The neoplastic ascites is almost always the consequence of tumor forms localized in other parts of the body that metastasize in the abdominal cavity causing precisely the pouring of liquids.
How is ascites diagnosed
How is the diagnosis made?
The diagnosis of ascites is made by a doctor on the basis of the clearly visible characteristics already mentioned, on the palpation of the abdomen and on the basis of tests that investigate the nature of the liquid.
The doctor will first evaluate the increase in volume and the globular appearance of the abdomen, the protrusion of the navel and the formation of any hernias, which are however not sufficient for a diagnosis of ascites but which address the clinical suspicion.
The evaluation continues with palpation of the abdomen, evaluating the mobility of the abdominal contents and the coexistence of air.
Using diagnostic imaging tools (ultrasound is widely used), you can see the amount of fluid present in the abdomen, adjusting how much of it must be withdrawn during the emptying maneuver.
Finally, after having performed an emptying maneuver ( diagnostic paracentesis ), the nature of the liquid is analyzed. But what are you going to analyze
The aspect of main interest is related to the presence of proteins, in particular the quantity of albumin is evaluated, but other aspects are also investigated such as the number of white blood cells (to exclude there are bacterial infections in place), the presence glucose, LDH (lactate dehydrognase) and if there are elements that can be connected to neoplastic processes.
However, we must not underestimate the importance of the simple observation of factors such as color, density, appearance and quantity: all characteristics useful for evaluating the nature of the liquid.
What are the therapies we have available to treat ascites
Let’s turn the page to find out.
What
therapies do we have available ?adequate therapy for ascites must be entrusted exclusively to a specialist doctor, the only one able to temporarily resolve the situation by means of an emptying maneuver called evacuative paracentesis which we will analyze shortly. The purpose of the specialist visit must be to identify and treat the systemic pathology that caused the collection of liquid and from there to implement the most suitable and effective therapeutic strategy. The liquid withdrawn is, as seen previously, analyzed for the purpose of a correct diagnosis.
In particular, the following will be analyzed from the aspirated liquid:
- Blood proteins and those present in the ascitic fluid;
- Number of white blood cells, in particular neutrophils, whose values ​​must be less than 250 / mm³;
- Culture test and antibiogram to identify the bacterium present and treat it with the antibiotic to which it is most sensitive;
- Glucose dosage, serum protein, bilirubin, hematocrit and search for the presence of tumor cells.
What is paracentesis and how it is performed
It is an invasive maneuver, performed in sterile conditions and carried out using medical instruments. The objective of this maneuver is to empty the abdominal cavity of the collected liquid, giving the patient a feeling of immediate relief.
A perforation is then made on the left side of the abdomen, following an imaginary line that connects the navel to the iliac spine (flank). Except in rare cases, the hole is never made in the right side of the abdomen because there is a risk of injuring the cecum.
After the emptying maneuver, pharmacological therapies are followed (often of a diuretic nature), also indicated exclusively by a specialist doctor, with the aim of going to treat the pathology that caused ascites.
The drug of first choice for the treatment of this condition is potassium canrenoate, (a drug that counteracts the action of aldosterone) according to the modality and dosage established strictly by the doctor. In case of ineffectiveness of monotherapy with this drug, other diuretics with a different mechanism of action such as furosemide or torasemide can be associated.
Also, to the patient suffering from ascitesit is advisable to follow a diet with a reduced sodium content (low sodium) and a restriction in the ingestion of liquids (maximum 750-1000 mL during the day).
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